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A client has a new prescription for guaifenesin. What information regarding the action of guaifenesin should the nurse include in the teaching?
- A. Decreases mucus production
- B. Reduces nasal congestion
- C. Increases cough production
- D. Reduces fever
Correct Answer: C
Rationale: The correct answer is C: 'Increases cough production.' Guaifenesin is an expectorant that works by increasing cough production to help clear secretions from the airways. Option A is incorrect because guaifenesin does not decrease mucus production but rather helps to make the mucus easier to cough up. Option B is incorrect as guaifenesin does not reduce nasal congestion. Option D is incorrect because guaifenesin does not have any effect on reducing fever.
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Which personality disorder is characterized by disregard for others and manipulative behaviors?
- A. Borderline Personality Disorder
- B. Antisocial Personality Disorder
- C. Histrionic Personality Disorder
- D. Narcissistic Personality Disorder
Correct Answer: B
Rationale: Antisocial Personality Disorder is the correct answer. This disorder is characterized by a pervasive pattern of disregard for and violation of the rights of others. Individuals with this disorder often display behaviors such as manipulation, exploitation, and a lack of empathy. Choice A, Borderline Personality Disorder, is characterized by unstable moods, behavior, and relationships. Choice C, Histrionic Personality Disorder, is characterized by attention-seeking behavior and excessive emotions. Choice D, Narcissistic Personality Disorder, is characterized by a grandiose sense of self-importance, a need for admiration, and a lack of empathy for others.
A client with a new diagnosis of type 1 diabetes mellitus is being taught about self-administration of insulin by a nurse. Which of the following instructions should the nurse include?
- A. Store the current bottle of insulin at room temperature
- B. Massage the injection site after removing the needle
- C. Pull back on the plunger after injecting the insulin
- D. Use each syringe up to six times
Correct Answer: A
Rationale: The correct answer is to store the current bottle of insulin at room temperature. Insulin should be stored this way to maintain its potency and effectiveness. Choice B is incorrect because massaging the injection site after removing the needle is not recommended practice and can cause bruising. Choice C is incorrect as pulling back on the plunger after injecting insulin can lead to injecting air bubbles into the tissue. Choice D is incorrect as syringes should not be reused multiple times due to the risk of contamination and inaccurate dosing.
What is a recommended nursing action for a client who experiences short-term memory loss after Electroconvulsive Therapy (ECT)?
- A. Provide cognitive-behavioral therapy
- B. Offer frequent orientation and reassurance
- C. Administer a sedative to improve memory recall
- D. Refer the client to a neurologist for further evaluation
Correct Answer: B
Rationale: The correct nursing action for a client experiencing short-term memory loss after ECT is to offer frequent orientation and reassurance. This helps the client feel supported and aids in memory retention. Providing cognitive-behavioral therapy (Choice A) may be beneficial for other conditions but is not the primary intervention for memory loss post-ECT. Administering a sedative (Choice C) is not recommended as it may further affect memory recall. Referring the client to a neurologist (Choice D) for further evaluation is not the initial action needed; offering support and orientation should be the first approach to manage memory issues post-ECT.
A nurse in an emergency department is preparing a change-of-shift report for an adult client who is transferring to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the report?
- A. The client has a do-not-resuscitate order.
- B. The client has a continuous IV of lactated Ringer's.
- C. The client was straight catheterized for 350 mL 2 hours ago.
- D. The client has Medicare insurance.
Correct Answer: A
Rationale: In an SBAR report, key information such as the client's do-not-resuscitate (DNR) status should be included as it directly impacts the client's care and treatment plan. Choices B and C are important details but may not be as critical for immediate care planning during the shift change. Choice D, the client having Medicare insurance, is important for billing purposes but does not directly impact the client's immediate care needs.
A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?
- A. Self-report of pain
- B. Nonverbal behavior
- C. Severity of the condition
- D. Vital signs
Correct Answer: A
Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.